Opioid Prescriptions and Headache Patients in Primary Care

My Two Cent Summary of a Study Presented at AAN At this year’s annual American Academy of Neurology (AAN) meeting, a study was presented on the prevalence of primary care doctors prescribing opioids for Migraine patients. In the past few years, the abuse of opioids has been a growing concern. The CDC states that “the quantity of prescription painkillers sold to pharmacies, hospitals, and doctors’ offices was 4 times larger in 2010 than in 1999”.1 Enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for a month. Due to the increased usage of opioids, there are large numbers of patients who become dependent on these painkillers and end up abusing them. Roughly 15,000 people die each year from prescription painkiller abuse. According to the CDC, for every 1 death there are 32 ER visits for abuse, 130 people who are dependent and 825 non-medical users of opioids.1 Because of these astonishing facts, one would assume that doctors would be extremely careful in prescribing opioids to Migraine patients, many of whom legitimately need this medication. However, a survey of 13 clinics between 2008 and 2010 showed that opioids tended to be prescribed more often than triptans to Migraine patients by primary care doctors.

Overview The objective of the study was to analyze how headaches are diagnosed and treated at the primary care level. A secondary question that arose was how the diagnostic code used for a patient influenced the treatment plan. The information collected did not include encounters (or appointments) with neurologists or Headache Specialists. Symptom Codes and Diagnostic Codes were used to find trends in opioid prescriptions. To understand the findings, here’s what you need to know about these medical billing codes. Symptom Code (784) – describes signs and symptoms a patient presents. For Headache patients the symptom code could describe tight muscles in the shoulders and neck, jaw pain and pain in various parts of the head (not confined to the area of distribution of any nerve). While these symptoms are common to Migraine, they could be caused by a hangover, Meningitis or Lyme’s disease.2 Diagnostic Code (346) – is used to group and identify diseases, disorders and adverse effects of drugs, chemicals and injuries. A diagnostic code is used when the doctor believes to have ruled out any other possible diagnosis and Migraine is determined to be the cause of the pain.3

The FindingsStatistic #1 55% of Headache patients received a symptom code (784). 42% of Headache patients received a diagnostic code of Migraine (346). 3% were categorized as “Other.” Statistic #2 30% of ALL Headache encounters were prescribed opioids. Of those who received a diagnostic code of Migraine (346), 36% received opioids while only 19% received triptans, which are considered non-addictive. A combination of opioids and triptans were more likely prescribed to patients who received a diagnostic code of Migraine (346) than a symptom code (784). Statistic #3 9% of Headache patients were classified as Heavy Users (having more than 7 encounters) and generated 45% of all total appointments in the 13 clinics surveyed. Heavy users are more likely to be prescribed opioids and less likely to receive triptans. Statistic #4 Heavy Opiate Prescribers (doctors who wrote more than 40 opioid prescriptions in 2 years) represented only 10% of the providers, but 65% of all opioid prescriptions written.

Study Conclusion

Symptom codes are used more often by primary care doctors than diagnostic codes.

The rate of opiate prescription by primary care doctors is high for headache patients, while the use of triptans is low.

There is an overwhelming need for an Electronic Medical Record based intervention in primary care clinics to monitor the overuse of opioids to treat headache patients.

My Two Cents The over-prescription of opioids is now limiting the access of the drug to those who are truly in need of it. Opioids are a quick and easy fix for a primary care doctor to prescribe who doesn’t have time or the resources to devote to every patient who is in pain. While they are a great medication for those truly need it, opioids don’t address the underlying problem. The Migraine still persists. If a primary care doctor diagnoses a patient with Migraines, but the patient does not respond to the first-line defense medications, a referral to a specialist should be the next step before these powerful addictive drugs are prescribed. An emphasis should be made on lifestyle changes, preventative meds, natural supplements and regular follow-up appointments. You can read the Abstract of this study here.

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Comments

I too have a similar level of Chronic Migraines and treatment protocols. I also have Rheumatoid and Psoriatic Arthritis.I completely agree with your stance of opioids. I have worked in the D&A field and know that there is a problem with people who do end up self-medicating and becoming addicted. There are times though all I would like is a stronger pain medication than what I currently keep in my arsenal of treatments.

Hi, interesting article. Since I have been going through this crazy world of Migraines and eventual chronic Migraines, I too have learned some important lessons. It most certainly is important to be treated by a neurologist who specializes in Migraine therapy. It also is a good idea to have any pain meds managed by a pain management specialist. I have been fortunate enough to get off of the Percocet. I have been fortunate to have had the benefit of some Botox therapy. Also, I was found to be having Ocular migraines, as well as Classic Migraines by my Ophthalmologist. Part of my problem related to unbalanced eye strength, and the need for a Prism prescription in my glasses. It has only been two weeks, but this has reduced the severity of my migraines to some degree.

I still do believe that Opiate pain medicine can be used to the benefit of Migraine Patients like us.

Crystal and Kimberly,
Thank you both for sharing your struggles with pain management. You’ve both clearly experimented with a variety of treatments to control the pain. Once I had been using Opioids for a while for my Migraines, my doctor suggested taking a 12-week pain management class that exposed me to alternative ways of dealing with the pain, just like you have both tried. Each person is so different and what works for you may not work for others. It is so frustrating when you have to prove to a doctor that you are not a drug-seeker, you just want relief.

Interestingly, I came across this article today from The National Pain report. Only about 4% of physicians are completing the required courses in pain management. And there are only 4,000 pain specialists in the US. It hightlights a serious problem. There aren’t enough docs to treat patients like us and the ones we do have access to are not properly trained and are therefore reluctant to prescribe opioids to patients who need them.

The article describes a new virtual way of teaching med students how to properly assess pain patients and suggest alternatives. It’s interesting and definitely needed.

Florida has a terrible problem with pain killer abuse, which has caused very strict regulation. I agree with the tougher laws – they are needed – but recognize that the laws cause problems for those who truly need them.

Wow! Our stories are so similar! I too have chronic migraines and have virtually tried every preventative and rescue medication, as well as all the usual, and unusual, treatments ie: physical therapy, acupuncture, bio-feedback & meditation, multiple & various pressure point injections, etc. I’ve also tried all the Triptans. Not only did they not work but they caused heart palpitations serious enough for them to recommend against further use, are contraindicated with the Only anti-depressant that’s ever helped (even a bit), and now I find out they’re really hard on liver & kidneys and should be used judiciously and with caution!! In summary, like it or not, the only thing that Does Work is opioids! I have a long, documented history of severe migraines and ER visits so you’d think that would make my Neurologist more comfortable prescribing them for me. Yet at every visit he comments about the increasing pressure Doctors are receiving from the CDC to limit opioid prescriptions and how I’m one of only two patients in their clinic receiving them for migraine. What I am tired of is every time I need to find a new Dr (moved, retired, or ineffective results) I have to “prove myself” all over again. Those of us with “treatment resistant” migraine pain are more tenacious in seeking specialty services and often more educated about migraine treatment options and what does and doesn’t work for us. Doctors, especially ER Drs, don’t always appreciate our knowledge and experience. It’s not their fault they don’t know a lot about migraine as they are trained in trauma medicine, but they don’t like to be questioned or corrected, that’s for sure, and apparently can’t physically say the words “I don’t know”! A sure fire way to Not Get the treatment you need is to try and tell them something they “don’t believe”!

I am one of the migraine patients who DO need Opiates. As I have had migraines since 1956, I have been on a plethora of medications, some pain killers, some migraine medications. I have tried reflexology, acupuncture, acupressure, bio feedback, meditation, distraction, herbs with the help of an herbalist, Native American Medicine Man with herbs, healing cleanses and smudging rituals, elimination diets, not to mention pain classes. The only two exercises I’ve been able to do for the past 14yrs are walking and swimming/water jogging, due to four small migraine induced strokes which really affected my balance and coordination, among other things.
My first Neurologist, with the medical plan that I’ve been on since 1980, was outstanding. He diagnosed me with migraines at that institution, found out that I had migraine induced prinzmetal’s angina, migraine induced epilepsy, what medicines I could and could not take, took my case files, sans identification info, to Migraine and Pain Symposiums, and Conventions all over the world on his own dime, off and on for five years, trying to find ways to help me, (I’ve nearly died on a few occasions due to my migraines). On one of these trips he heard promising results about Stadol Nasal Spray. I’ve been on this medication now for close to 22yrs. It helps, but by itself doesn’t relieve enough of the pain. I’m not talking getting “Rid” of the pain, just getting it down to a “6,” on the Pain Scale, (0-10, with “10” being the worst pain ever), a “3” would be nice! So many migraine medicines that I’ve tried either don’t work, don’t work any more, I’m allergic to, can’t take due to other medications I’m on, or other conditions where they are contraindicated. I’m left with very few choices of those that are available. That wonderful Neurologist retired 8 or 9 years ago, and my primary who as also outstanding, retired 5yrs ago. My current doctor only recently referred me to a Neurologist/Migraine Specialist. I’ve had one meeting with her. Both medicines she thought might help, after I looked them up, are contraindicated due to other medical conditions that I have. There just isn’t much out there for someone like me.
My migraines are truly daily. They haven’t been below a “5” in 25yrs. I don’t go anywhere, or do anything except occasionally grocery shopping, doctor’s visits, or going to the pharmacy for medications. I don’t see my friends (though we do chat on the phone or computer), I don’t go to church any more, I don’t go to any movies, once or twice a year I try to go out for dinner with my husband of 29yrs, but I don’t do anything else. I spend all day and half of the night using what “Little” medicine my primary doctor will allow me, (can’t get addicted to narcotics because you won’t have any “Usable” Organs left to harvest when your gone … BIG MONEY in that you know! Nothing left on this body, however), plus using meditation, distraction, and or bio feedback … in my house, usually in my bedroom.
By the way, as of the “last” time I looked this up, the United States is the only county that does NOT treat “Pain” as a problem. They use some pain killers as they are treating the patient for their illness or injury. In other countries they treat Pain as a problem, and as part of the patient’s healing process, and we did once in this country too, and knew that patients in “Less” pain, (not Zero pain), heal more quickly and with less complications than if you do not address the pain issue. Why the U.S. has adopted the, “Eat only sunshine and rainbows, don’t use ANY medication, just think Happy Thoughts and you’ll be fine” attitude, I don’t know. What I do know, is that at one time we were leaders in Health, Medicine, Education, and Work Force for our people. Now, we are barely hanging on as a First World Country trying to play catch up with the others, because we are allowing powerful companies, industries (including Big Pharma) and MONEY to make our Choices, Rule our country and putting THEIR concerns first rather than putting our PEOPLE first, including our health and well being.

P.S.
Sorry for the rant at the end, but I just can’t understand anything else that would explain our failure in how we are treating our people over here, especially Medically.